Basic Information
Provider Information | |||||||||
NPI: | 1295985810 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PHIPPS | ||||||||
FirstName: | AIMEE | ||||||||
MiddleName: | LYN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A.-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BOLLINGER | ||||||||
OtherFirstName: | AIMEE | ||||||||
OtherMiddleName: | LYN | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NOT AVAILABLE | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3205 N ACADEMY BLVD | ||||||||
Address2: | SUITE 130 | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809175101 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7196325700 | ||||||||
FaxNumber: | 7193447837 | ||||||||
Practice Location | |||||||||
Address1: | 410 GOLD PASS HTS | ||||||||
Address2: |   | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809063882 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7196325700 | ||||||||
FaxNumber: | 7193447817 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/19/2008 | ||||||||
LastUpdateDate: | 04/04/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2670 | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 52681548 | 05 | CO |   | MEDICAID | COAAA3812 | 01 | CO | MEDICARE NUMBER | OTHER |